Recalcitrant Sternal Bleeding
Sternal bleeding usually stops with compression and often by closing the sternum. Recalcitrant bleeding can usually occur due to #Coagulopathy #Inter mammary collaterals - in coarctation, post classical BT shunt and left subclavian origin block. Sternal bleeding can be classified into #Bleeding from wire holes #Bleeding from the marrow #Bleeding from sternal fractures. #Bleeding from the internal mammary artery or its branches. Bleeding from wire holes This is a common occurrence and usually occurs in wires through the body of the manubrium . If there are multiple bleeding wires a coagulopathy must be suspected. Bleeding usually stops with correction of the coagulation defect but may require placement of a figure of 8 stitch or a purse string around the wire. If it fails to control this, removal of the wire, cauterization of the hole with a cautery and filling the defect with bone wax may at times work.It may be useful at times to use the tip of a fine Mixter forceps wedged in the hole to cauterize the bleeder. A point to be remembered is that bleeding from the upper sternal surface needs to always be controlled too as closure of tissues above the sternum may just allow that bleeding to track down and cause internal bleeding. It is better to confirm that is not occurring by obtaining hemostasis of the upper table too either by temporary manual compression while checking the lower plate or by placing an appropriate suture. Excessive use of cautery prior to a hemostatic stitch may denude the periosteum making it difficult to place any hemostatic stitches in the lower table of the sternum so cauterization when done around a wire bleeder must be done carefully.It may be wise to place wires parasternally in a coagulopathic patient instead of through the sternum. Bleeding from the Marrow Bleeding from the marrow is usually stopped by application of bone wax or the use of gelatin foam powder with Vancomycin paste. Closure of the sternum usually stops the bleeding. it is important to control bleeding from the periosteal edges with judicious use of cautery. Bleeding from the marrow can be particularly troublesome when the sternum is kept open packed . This can usually be managed by *'Compression' with gauze *'Application of strips' of Surgicel or Gelatin foam, coseal and platelet gel *By suturing a piece of bovine pericardium or a temporary sheet of plastic to the edges of the sternum locally tamponading the bleeding. *'Ligation' of the internal mammary arteries may be used. A coagulopathy work up must be done. Raised venous pressure and intermammary collaterals may also cause troublesome sternal oozing. Bleeding from sternal fractures A sternal fracture usually stops bleeding with the application of a bone wax . Closure of the sternum with a figure of eight wire or fixation of the sternum with an appropriately placed wire / plates or a Robiseck weave may be required. *'Placement of U sutures' in the parallel intercostal space often controls the bleeding. * Packing the sternum with gelfoam / surgicel and an over and over running suture with No 1 Vicryl running from the intercostal space to the free margin encompassing the fractured area may at times compress the fracture especially if it is a horizontal one *In case of unstoppable bleeding ligation of the ipsilateral internal mammary artery *'Sternectomy' (local or total) depending on the nature of the problem may be required as a last resort. Bleeding from the internal mammary artery Bleeding from inadvertent puncture of the internal mammary artery may occur if the wires are taken parasternally. This may stop by placing a *'Suture around the bleeding wire' but it may lead to bleeding into the pleural space if the suture is not adequately placed. *'Ligation of the internal mammary' above and below the bleeding site or even extraction of the wire and ligation of the bleeding spot may be required. Coagulopathic patient Bleeding from sternal wires and diffuse bleeding from the sternum is usually a manifestation of coagulopathy. Correction of the particular hemostatic defect would be required and a coagulation workup including standard tests and a thromboelastogram may be required *Treatment of the associated coagulopathy with clotting factors and antifibrinolytics and freshest possible blood if available with maintainance of normothermia helps in controlling the bleeding. A period of sternal closure and active observation for tamponade may be required with timely reexploration. Restitution of clotting factors and sternal compression by closure can stop the bleeding. If this fails *'open packing of the sternum' till coagulopathy abates *'Suturing of bovine pericardium or a plastic wrap'(temporary) to locally tamponade the bleeding. Glues can be injected into the space between the bovine pericardium and the sternum. *Platelet gel can be applied to the bleeding edges *'Recombinant Factor VII' may be used in desperate circumstances - this would be an off label use. *'Ligation of the internal mammary arteries' to devascularize the sternum may be used in desperate circumstances. *'Total Sternectomy' may also be used if internal mammary ligation also fails. Even with sternectomy correction of the basic coagulation defect remains to be corrected. Once coagulopathy has abated , pectoral advancement flaps and / or various sternal reconstruction methods including sternal prosthesis may be used at a later date electively. Intermammary collaterals These can cause problems on sternal entry and can cause massive hemorrhage. Problems during Primary Sternotomy These collaterals can cause bleeding postoperatively and may need suture ligation and cautery with rigorous management of post operative pressures and if required multiple reexplorations to control the specific reopened bleeding points. Ligation of the internal mammary may be done as only a last resort as they can represent an important collateral supply to the involved limb but may have to be done while monitoring the vascularity of the affected limb to see if there is sufficient blood supply via other collaterals via the anastomosis around the scapula. A temporary bull dog or hemoclip can be placed to observe the effect.If limb ischemia becomes significant , a carotid subclavian bypass may be required to be placed but can be pretty difficult due to extensive collaterals.